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Book reviews
LIMBIC SEIZURES IN CHILDREN.
By C. Munari, G. Avanzini, A. Beaumanoir and L. Mira.
2001. Eastleigh: John Libbey.
Price £39. Pp. 258. ISBN 0-86196-595-7.
The concept of limbic seizures was introduced by Broca
in the late 19th century, though Willis had already used
the term `limbus', a fringe or border, in an anatomical
treatise 200 years earlier. In addition to being the
borderland of Hell, Limbo, the ablative of the Latin
`limbus', is de®ned as any unsatisfactory place of
consignment or oblivion; an uncertain or intermediate
state; a prison. When considering limbic seizures, such
descriptions seem apposite, not only in anatomical and
functional terms, but also from the viewpoint of seizure
semiology and particularly in relation to the possibility
that very unpleasant subjective sensations may occur. The
editors and their authors have undertaken a dif®cult task,
and are to be commended for the production of a multifaceted, well-referenced book, which follows a colloquium
aimed at outlining the speci®c expression of epilepsies
involving the limbic structures in children and establishing a consensus on the evidence relevant to the clinical
management of these epilepsies.
Precise information on seizures originating in the
limbic system is rather sparse in the paediatric age
range, particularly in very young children and infants.
Therefore, it is, perhaps, only to be expected that some
chapters produce data that are largely con®ned to patients
in their second decades or to adults. The contributions
devoted more or less completely to children include those
on pathology; clinical expressions of seizures, usually
with simultaneous EEG ®ndings, and sometimes video
recording; EEG; medical therapy; surgical therapy; and a
consideration of whether a benign limbic epilepsy exists
in childhood. It is disappointing that the chapters on
neurovegetative manifestations, language and speech disturbances, mesiotemporal seizures and symptoms differentiating `temporal' from `frontal' cortical partial seizures
relate mainly to adults. However, their inclusion in this
text adds emphasis to the paucity of information on these
subjects in younger age groups and the need to devote
more attention to the special circumstances of childhood.
An extensive historical review concludes by highlighting questions relevant to the overall theme of agespeci®city. These address the uncertainties about the
semiology and the timing of initial events deemed
responsible for lesions in Ammon's horn, and of the
evolution of such pathology. The authors of the chapter
ã Oxford University Press 2002
on anatomy believe that the limbic system de®nes only
an anatomical entity and not functional properties, though
those who wrote the contribution on functional organization of the limbic system would no doubt dispute this.
Both these chapters are written in styles which are
intelligible to the non-specialist in these ®elds. In
particular, the diagrams explaining the anatomical groups
within the limbic system are clear and informative. The
importance of timings in neurogenesis and neural migration is emphasized. For example, neurones of layer 1 of
the neocortex and limbic cortex are developed between 5
and 8 weeks of gestation (maximally ~6±7 weeks); and,
the latest to develop, dentate granule cells of the
hippocampus are not formed until 15±40 weeks of
gestation (maximally 19±32 weeks). In addition, there
are three different processes involved in migration:
`inside-out' (cells which migrate ®rst are overtaken to
more distal sites by those migrating later) in the
neocortex, parahippocampal region, CA1, CA2 and CA3;
`outside-in' (cells migrating ®rst remain the outer layer)
in the granular layer of the dentate nucleus; and,
supragranular±infragranular in the dentate gyrus. Clearly,
there is considerable potential for disruption of these
sequences if adverse events occur during foetal life.
Pathophysiological consequences would then seem likely.
The important possibility that function in the limbic
system might alter with age, particularly in the very
young child, is not addressed. On the other hand, a
contribution on experimental seizures in young rats found
that expression and propagation of hippocampal seizures
are age-dependent; and gives evidence to suggest that
intrahippocampal cortical heterotopias can contribute to
generalization of hippocampal focal paroxysmal activity.
The reviews of clinical material are particularly relevant to the practising child neurologist. It can be very
dif®cult to know whether or not changes in posture,
movement patterns, behaviour and autonomic phenomena
constitute seizures, especially in the very young and the
handicapped, who are unable to verbalize unpleasant or
other sensations. When the authors speci®ed the age
ranges of their groups and examined infants or pre-school
children separately, the seizure semiologies were not
consistent throughout childhood, though complete agreement between the groups of authors was not reached.
When patients were de®ned by age, automatisms were
considered common in pre-school children, but when
identi®ed by the presence of a tumour, automatisms were
reported as rare or minimal in the same age range. In two
contributions, seizures similar in characteristics to infant-
Book reviews
ile spasms, but con®rmed by EEG as arising in the limbic
system, were noted in very young children. On the whole,
phenomena observed in or reported by children over the
age of 6 years were comparable with those experienced
by adults. Although most authors reported the ®ndings in
relatively small cohorts, in all, there is a lot of
information on the many forms that limbic seizures can
take. A well-argued chapter considers the connection
between febrile seizures and limbic epilepsy and tends to
favour the presence of a predisposing event or circumstance for the complex febrile seizure, which is followed
by hippocampal pathology. Interesting discussions on the
pathology of hippocampal lesions that are identi®ed in
children emphasize that mesial temporal sclerosis is a
very rare ®nding, and is virtually unknown before the age
of 4 years. This again underlines the need to consider any
disorder of childhood as an evolving process, in line with
continued maturation of anatomical and functional
aspects.
The chapter on memory disturbances in early hippocampal dysfunction is fascinating. However, it would
have been helpful to have been given the ages of the
subjects described. This is followed by a very good and
very critical review of the literature on psychic alterations
in temporal lobe seizures in children, which concludes
that, although neuropsychological problems are common
in children with epilepsy, these are not speci®cally related
to temporal lobe epilepsy, but are more in keeping with
the overall cognitive status. The information on perceptual
and intellectual disturbances is somewhat sparse and
relates almost entirely to a surgical series and its
outcome. Of the chapters on investigation, the one on
ictal EEG looks at a surgical sample and emphasizes that
it is important to differentiate limbic seizures from those
arising from the temporal cortex. Rhythmic spikes or
rhythmic slow wave discharges, previously considered to
be typical of temporal lobe seizures, were seen on only
three of 57 occasions, whereas, characteristically, ictal
activity consisted of well-localized fast activity or welllocalized ¯attening. Previous information on ictal SPECT
in children of <4 years of age is almost completely
lacking. The usefulness of this investigation, particularly
when co-registered with MRI, is well emphasized. The
main messages of the chapter on MRI are that
hippocampal abnormalities are often just one feature of
more extensive developmental anomalies, and, that
hippocampal signal abnormalities on MRI do not always
mean hippocampal sclerosis. It was once again underlined
that hippocampal sclerosis is much rarer in children than
in adults.
There are numerous interesting reports on the various
expressions of limbic seizures in children, but the second
aim of the book, a review of medical and surgical
therapies, is very brief. However, such data can be found
elsewhere without too much dif®culty. In fact the chapter
on surgery contains a wealth of information on electro-
437
clinical correlations that is at least as useful as any other
in the book.
I have enjoyed reading Limbic seizures in children. I
can thoroughly recommend it to all those who work in
paediatric epilepsy. Those whose remit is the neurology
of adults, and who wish to enlarge the breadth of their
knowledge of the early histories and development of their
patients with epilepsy, will ®nd much of relevance and
interest in this text. It is an essential source of
information on a group of conditions which are usually
poorly de®ned. It should act as a spur to the further
investigation of this very challenging area of epilepsy.
Dr Sheila Wallace
Llanvapley,
Abergavenny, UK
NITRIC OXIDE AND FREE RADICALS IN
PERIPHERAL NEUROTRANSMISSION.
By Stanley Kalsner.
2000. Basel: Birkhauser Verlag AG.
Price $89.95. Pp. 357. ISBN 3-81764-0070-3.
This book represents the 2nd volume in a series entitled Nitric
Oxide in Biology and Medicine. My initial reaction when
considering this book was: not another book on nitric oxide
(NO)! However, this feeling soon disappeared when I started
to read the book.
A major bene®t of this book is that each of the 15 chapters
are almost stand-alone reviews written by the appropriate
experts in the ®eld. Furthermore, there is little overlap and
each chapter is self-contained, i.e. a (comprehensive) reference list is included at the end of the chapter. In addition, in
the majority of the chapters, actual experimental data is
shown in order to support the various concepts and hypotheses being discussed.
The ®rst chapter of the volume considers the origin and
evolution of nitric oxide signalling. A wealth of intriguing
information is covered, e.g. NO formation in invertebrates
and plant tissues. Leonid Moriz has also been very thorough
in searching the literature, and references from 1965 and 1973
have been uncovered that consider NO formation by
mitochondria, a subject that is very much in vogue today!
Whilst some of the titles of the various chapters my not
initially appeal to all, e.g. Chapter 2: `the nitrergic transmitter
of the anococcygeus', I found that in many cases a dip into
such a chapter was worth it. Often, as in the case of Chapter 2,
information can be found that may be relevant to all ®elds of
NO biology and medicine. Of particular interest (to me at
least) was the discussion relating to the nature of NO release
from non-adrenergic non-cholinergic (NANC) nerves. In
view of the unstable/reactive nature of NO, it has been
proposed that `guardian' molecules are concomitantly
released in order to optimize nitrergic transmission. One
438
Book reviews
candidate molecule is ascorbate, the release of which appears
to be increased under depolarizing conditions.
The interaction of NO with other NANC inhibitory
neurotransmitters and the proposed roles of NO in penile
erection, bladder function, the enteric nervous system and
lung tissue are considered in Chapters 3±6. Other putative
neurotransmitters originating from the endothelium that
mediate smooth muscle hyperpolarization include ATP and
possibly K+. However, the mechanism whereby the latter
simple ion is released from endothelial cells remains to be
elucidated. With regards to penile erection, NO has certainly
made an impact, not least for the pharmaceutical industry, in
the form of Viagra (sidena®l). The mode of action of this drug
is considered in Chapter 4 along with the (patho)physiological roles of NO for penile erection and bladder function.
Turning to the gastrointestinal tract, there is now strong
evidence to suggest that NO is an inhibitory neurotransmitter.
In Chapter 5, Kenton Sanders and Kathleen Keef consider the
data to support this and draw analogies with classic
neurotransmitters, i.e. methods of release, substrate recycling
and inactivation. The airways develop embryologically from
the foregut. Thus, the demonstration of NANC neurotransmitters in the respiratory chain was not unexpected. In
Chapter 6, the role of NO in the bronchodilator response is
considered. Furthermore, experimental data, derived from a
range of model systems (guinea pig, cat, rabbit, horse, ferret
and human) are reviewed. It is certainly clear after reading
this chapter that species differences occur in the neural
control of airway relaxation. As NANC bronchodilator nerves
represent a major pathway in the human airway, it is not
surprising that this system is the subject of attention with
regard to the pathogenesis of disorders such as asthma.
However, for humans at least, the NANC response appears to
be normal in asthmatic patients. In contrast, this response may
be impaired in cystic ®brosis due to accelerated degradation
of NO.
The resistance blood vessels have a diameter of <400 mm
and play a key role in regulating the microcirculation to
organs. Chapters 7 and 8 of this book cover the regulation and
mode of action of NO in controlling relaxation of this vessel
type. These chapters consider the source of NO, i.e.
endothelial cells and perivascular nitrergic nerves and the
interaction of NO with other neurotransmitter types such as
acetylcholine. With regard to the latter, NO and acetylcholine
may be produced by the same nerve terminal (choinergic
nitric oxidergic nerve). Acetylcholine it appears may modulate NO release via pre-synaptic muscarinic receptors.
NO has been described as being a pluripotent molecule,
having both physiological and pathophysiological effects.
The majority, but not all of the remaining chapters consider
the role of NO in the pathogenesis of various disease states.
Migraine attacks are known to involve alterations in the
regulation of tone in intra- and/or extra-cranial blood vessels.
Consequently, NO has been proposed to play a role in
migraine. The 9th chapter of the book considers the evidence
for this suggestion. The data presented certainly suggest that
individuals prone to migraine attacks display an increased
sensitivity to NO. Furthermore, pharmacological blockade of
NO generation, following administration of non-speci®c NO
synthase inhibitors, appears to convey some relief with
regards to headache severity, phonophobia and photophobia.
However, the use of such an agent was, as predicted,
associated with alterations in mean blood pressure and heart
rate. Despite this, the authors suggest that the development of
drugs targeted to speci®c isoforms of NO synthase could lead
to the development of an effective treatment for migrane. The
obvious question here is which isoform? One intriguing
possibility is the inducible form of the enzyme which is
induced following cytokine exposure. Recent evidence suggests that, following cortical spreading depression, substantial amounts of NO may be generated via this enzyme.
The following chapter (10) covers the possible presynaptic modulation of nitrergic transmission and deviates
from the theme of the preceding and subsequent chapters,
which tend to focus on the potential role of NO in disease
states. Despite this, the chapter is worthwhile, and putative
pre-synaptic mechanisms whereby NO formation may be
regulated are considered, e.g. negative feedback of NO
synthase activity by NO itself and alterations in intracellular
Ca2+ availability.
With regard to polymorphonuclear neutrophils (PMNs), it
has, not unreasonably, been assumed that NO formation is
derived solely from the activity of the inducible isoform of
NO synthase. However, this assumption has been challenged
and in Chapter 11 the evidence for the existence of a
functional constitutive NO synthase (neuronal NOS) in PMNs
is considered. It is postulated that the recruitment of PMNs
into the lung, during infection and in¯ammation, is regulated
by a constitutive NO synthase. Studies with appropriate
knockout mice convincingly support this suggestion, i.e. data
are presented in this chapter to suggest that, in the absence of
NOS, increased recruitment of PMNs occurs following
lipopolysaccharide exposure.
Peroxynitrite (ONOO±) formed by the favourable reaction
between NO and superoxide is considered by many to be the
actual species responsible for the cytotoxicity associated with
inappropriate/excessive NO formation. Chapters 12±14 consider the putative pathogenic mechanisms whereby ONOO±
may contribute to disorders such as motor neurone disease
and diabetes. Certainly, the evidence that is presented is
persuasive, and elaborate mechanisms with supporting
informative ®gures are provided. Whether formation of
reactive nitrogen species in such conditions is the critical
key event or simply a surrogate marker of disease progression
remains to be elucidated.
The ®nal chapter considers the potential clinical use of
modulators of NO metabolism. Already NO, delivered by
inhalation, is yielding promising results in the treatment of
acute respiratory distress syndrome and pulmonary hypertension. Arginine supplementation is also discussed. This
amino acid is the substrate for all isoforms of NO synthase
and was not considered to be rate limiting for NO formation.
Book reviews
However, in heart failure, oral arginine is reported to increase
peripheral blood ¯ow. As expected, this chapter also
considers the use of NOS inhibitors in conditions such as
septic shock and the need for speci®c NO synthase inhibitors
is reiterated.
In conclusion, in view of the monumental amount of
literature relating to NO, this book will be invaluable to those
researchers with an interest in the peripheral nervous system
and who have not recently performed a literature search on
NO.
Dr Simon Heales
Institute of Neurology,
Queen Square,
London, UK
THE OXFORD HANDBOOK OF MEMORY.
Edited by E. Tulving and F. Craik.
2000. Oxford: Oxford University Press.
Price £45. Pp. 714. ISBN 0-19512-265-8.
The intricacies of human memory have fascinated philosophers and scholars for millennia. It is not surprising that it is
so. Memory represents a key psychological process, allowing
us to re-experience events from our past which may have
taken place hours, days, months or even many years ago.
Memory underlies other key psychological and behavioural
processes such as perception, language and movement. And
memory is also crucial for our sense of consciousness:
without memory we would have no real sense of self or
personal identity.
Because memory and learning have such a profound
in¯uence on other aspects of human existence, the scienti®c
study of memory within experimental psychology (and the
related cognitive and brain sciences) hasÐhistoricallyÐbeen
inseparable from the scienti®c study of mental life and
behaviour. Moreover, not only has memory fascinated people
for centuries, butÐin the present dayÐit is one of the most
active and fertile areas of contemporary psychological
thought and practice. However, Tulving and Craik note that
this is the ®rst handbook of memory that has ever been
published, and suggest a possible explanation: they make the
point that memory research has perhaps been too successful
for its own good. The case is made by Tulving and Craik that,
such has been the pace of growth in the ®eld, it has not been
possible until the present day for the body of contemporary
understanding in the ®eld to be neatly encapsulated in a
medium of this kind.
Memory is a complex, diverse and heterogeneous entity.
How does one begin to try to de®ne its features, characteristics and organizing principles? In this volume, Tulving and
Craik de®ne memory as `the ability to recollect past events
and to bring learned facts and ideas back to mind'. However,
Tulving and Craik themselves acknowledge that an adequate
439
de®nition of memory must necessarily incorporate other
aspects of this complex and wide-ranging phenomenon (or
phenomena?), including, for example, both conscious and
non-conscious aspects of memory. In his concluding chapter
to this volume, Weiskrantz cites a 1990 de®nition of memory
from Michael Eysenck `the demonstration that behaviour has
been altered as a consequence of the previous storage of
information at some point in time ranging from a few seconds
to several decades'. Weiskrantz, however, takes issue with
such a de®nition as being too narrow and restrictive. With
respect to the range of topics covered in this volume,
Weiskrantz notes that the science of memory is now far richer
than such a traditional psychology dictionary de®nition
would imply. He argues that memory lies at the core of our
whole mental life, behaviour and sense of personal identity.
The raison d'eÃtre for this handbook is therefore well justi®ed.
The Oxford Handbook of Memory was, according to the
editors, compiled to summarize the current state of the
science of memory (with the emphasis on science), and it
succeeds in this goal. As might be expected from the world
renown of the editors, the handbook provides a wide-ranging
and penetrating coverage of the ®eld of memory research.
Endel Tulving and Gus Craik are both leading memory
scholars and founding fathers of the highly in¯uential
`Toronto school' of memory. They are responsible for
articulating some of the key concepts in the contemporary
memory literature (concepts such as `levels of processing'
and `encoding speci®city'), and need no further introduction
to anyone who has even brie¯y surveyed a memory textbook
over the past 30 years. Indeed, over the past several decades
in which Craik and Tulving have been highly in¯uential in the
®eld, a genuine science of human memory has begun to
emerge. This book provides an insightful overview of the era
in which the area has really come of age, ®rst in terms of
verbal learning and memory (the era in which Craik and
Tulving `cut their teeth' as researchers), more latterly in terms
of new technologies such as brain imaging and transcranial
stimulation (which have, at least in theory, enabled
researchers to view the neural mechanisms of memory in
action).
In reviewing this volume, it is interesting to re¯ect on the
sea change that has occurred in experimental memory
research over the past few years with respect to the particular
question of its neural underpinnings. The editors here espouse
a pluralistic framework when considering memory and
memory-related phenomena. Nevertheless, they argue for
the importance of an understanding of the neural components
of different elements of memory (such as acquisition, storage
and retrieval). In so doing, Tulving and Craik adopt an overtly
cognitive neuroscienceÐas distinct from a functionalist,
`black box' or purely cognitiveÐperspective on memory.
Thus, with respect to (i) the subjective experience of memory,
(ii) the behaviours emanating from the experience of memory
and (iii) the neural mechanisms of memory, Tulving and
Craik state that `each level can be understood in its own
terms, but any ®nal theory of memory must also show how the
440
Book reviews
different levels of description map onto each other'. This is a
contentious issue, and it would not be appropriate here to
debate the pros and cons of the particular variant of the
cognitive neuroscience perspective adopted by Tulving and
Craik. What I merely wish to point out here (and of especial
relevance for readers of this journal) is the following: that two
eminent researchers who grew up within the traditions of the
functional school of memory research (i.e. within the verbal
learning tradition, as it would have been referred to then)
haveÐin making a statement such as thisÐpositioned
themselves at the start of the 21st century ®rmly within the
cognitive neuroscience school of contemporary work. Indeed,
this position is clearly re¯ected in the contents of this book.
Individual chapters of the book are written by distinguished
workers in the ®eld of memory research, providing insight
into the current state of the art in their spheres of expertise, as
well as identifying challenges for the future. Topics included
in this volume cover many important areas, for example: the
development of memory, memory in the laboratory versus
memory in the outside world, memory decline, the organization of memory and theories of memory.
Below I outline in a little more detail the organization of
the book and some of the topics covered, before brie¯y
summarizing some of the points raised. There are, of course,
many ways in which a book of this kind could have been
organized, some more arbitrary than others. The book is
divided into four main sections entitled `Study of memory',
`Memory in the laboratory', `Memory in life' and
`Organization of memory'.
The ®rst section of the book, on the theme of `Study of
memory', provides an overview of the history of memory
research and its in¯uential concepts and methods. This
section sets the scene for the remainder of the book by laying
out some basic principles and suppositions within a historical
context.
Within the second section of the book, entitled `Memory in
the laboratory', the chapter authors concern themselves with
how memory has been studied within the experimental,
scienti®c tradition (that is, with respect to the verbal learning
and cognitive methodologies). This section provides a survey
of the major hypotheses, methods, results and conclusions
that form the core of the contemporary experimental science
of memory. This section of the book includes subsections on
`Acts of memory' (including considerations of short-term
memory, encoding and retrieval, transfer and expertise),
`Contents of memory' (serial learning, remembering actions
and words, and distortions of memory), `Re¯ections in
memory' (memory judgements, source monitoring and
metamemory) and `Awareness in memory' (recollection,
familiarity and the process dissociation procedure, remembering and knowing, and nonconscious forms of human
memory). The second section of the book therefore provides
appropriate coverage of both the behavioral and subjective
(i.e. conscious re¯ection, awareness) perspectives on human
memory.
Within the third section of the book, entitled `Memory in
life', the chapters deal with memory in the `real world' (as
opposed to the laboratory). There are subsections here on
`Memory in development' (memory in infancy and early
childhood, socialization of memory, and memory and theory
of mind) and `Memory in use' (remembering life experiences,
control processes in remembering, long-term maintenance of
knowledge, remembering spaces and memory for emotional
events). The next subsection picks up the developmental
theme again, with a consideration of `Memory in decline', an
area of tremendous current interest given the `ageing
population' that is currently occurring in the vast majority
of Western countries. This subsection covers memory
changes in healthy older adults, memory in the ageing
brain, selective memory disorders and memory in the
dementias.
The fourth and ®nal section of the book is entitled
`Organization of memory'. It is broken into two further
subsections, the ®rst entitled `Neural substrates of memory'
and the second entitled `Theories of memory'. The ®rst of
these two subsections covers current work investigating the
relationship of behavioural and subjective aspects of human
memory to neural mechanisms: the neuroanatomy of memory, the medial temporal lobe and the hippocampus, brain
imaging and memory, event-related potential studies of
memory and psychopharmacological perspectives. The second subsection in this ®nal part of the book seeks to bring
together many of the ideas and ®ndings previously presented.
It provides chapters on the adaptive nature of memory,
memory models, connectionist models of memory, episodic
memory and autonoetic awareness, theories of memory and
the `memory systems of 1999'. Finally, in his epilogue Larry
Weiskrantz considers `the story of memory, and memory of
the story'.
As highlighted in this volume, studies in memory research
have now placed us in a position where we have a variety of
richly worked theoretical frameworks at our disposal. We can
use these to seek to understand and explain the complexities
of different memory-related phenomena. In reviewing the
rich and extensive world of memory research, Tulving and
Craik make the case that `accepted facts about memory are
remarkably ®rm', and argue that the major present-day
uncertainties about memory concernÐratherÐhow to interpret the body of now well-established ®ndings. An example in
point (and an area covered in the book) might be the highly
controversial `recovered memories' literature of recent years.
Do these `recovered memories' in fact predominantly re¯ect
the re-emergence of veridical memories for actual events that
occurred in one's autobiographical past (such as incidents of
child abuse, to cite some of the most controversial circumstances), orÐgiven the highly reconstructive nature of human
memory, reported in the literature since the time of Bartlett in
the 1930sÐare these, in fact, memory distortions created by
top-down in¯uences and suggestibility? (Of course, the
possibility exists that some elements of each of these
Book reviews
scenarios may occur both within and across different
individuals.)
The Oxford Handbook of Memory provides the reader with
a sound and thorough grounding in current theoretical
memory frameworks and the methodologies and empirical
®ndings on which they are based. Its coverage largely relates
to the experimental psychology of memory, and its sibling
disciplines: neuropsychology, cognitive neuroscience and
developmental psychology. As the editors acknowledge,
other lively areas of current and past research, for example,
pertaining to the science of animal memory, had perforce to
be omitted from this volume. One useful feature of the book
for workers in related academic and professional disciplines
(such as law and medicine) is that the ®ndings are not
presented in a theoretically sterile environment. Rather,
having ®rst conveyed the important principles to the reader,
several chapter authors then neatly convey the rami®cations
of the ®ndings and theories for those working in a more
applied context. This provides useful information to the
applied professional; for example, for the clinician who
wishes to learn more about the relevant principles of memory
that will enable him/her to convey information to patients in a
more memory-sensitive manner, or to the lawyer or judge
who needs to know about the strengths and weaknesses of
human memory, and when and where this capacity (or, more
correctly, capacities) should and should not be trusted.
Of course, with a book of this nature (and having edited
works on memory myself), one cannot hope that the ®nished
product will be absolutely up-to-date with respect to every
single niche in the ®eld, such is the fertility of modern day
memory research. For example, while there is coverage in the
book of the ®eld of false/distorted memories and recovered
memories (very active and controversial areas over the past
decade), there is scant coverage of change blindness, which
many would consider to be a memory-related phenomenon.
Indeed, more generally, the focus of the book is on long-term
memory phenomena, with relatively less coverage of working
memory and related processes. This may re¯ect the overall
focus of the book, which seems to be more North American
than European in its theoretical orientation.
With respect to its audience, I would suggest that the book
would be most useful for advanced undergraduates, beginning graduate students, healthcare professionals such as
physicians and other professionals who may have relevant
work-related interests, such as lawyers and social workers.
Informed laypeople may well also ®nd sections of the text to
be quite accessible andÐwithout doubtÐinformative.
Jonathan K. Foster
Department of Psychology,
University of Western Australia,
Perth, Australia
441
A DISEASE ONCE SACRED. A HISTORY OF THE
MEDICAL UNDERSTANDING OF EPILEPSY
By Mervyn J. Eadie and Peter F. Bladin
2001. Eastleigh: John Libbey.
Price £24. Pp. 248. ISBN 0-86196-607-4.
Epileptic convulsions can be understood, as `the result of
experiments made by disease on the brain of man'. (John
Hughlings Jackson, 1875).
Rather than launching into ancient relics of epilepsy, Eadie
and Bladin start this work with an excellent, concise account
of the current knowledge, which forms a sound backdrop to
their history.
The topics are covered in four sections. The ®rst deals
with the present day understanding of epilepsy and
compares it with the thinking of the past. It traces
these notions on a chronological basis. Then we read
about the clinical manifestations of epilepsy recognized
by physicians from ancient times through the renaissance
to Jackson and the 19th and 20th centuries. The meaning
of words related to epilepsy forms a kind of index of the
change of ideas with the growth of knowledge. The third
section considers how views about the nature of the
epileptic process evolved from the supernatural to the
cerebral, and biological concepts. The ®nal section
pictures the fascinatingly wide range of treatments for
epilepsy, again considering the supernaturally founded
measures and those based biologically, from ancient times
through the Jacksonian era, to the present. Insights into
epilepsy derived from its history form the conclusion.
We learn that epilepsy has been known for at least 3000
years. Basic concepts surrounding epilepsy in ancient Indian
medicine were re®ned and developed during the Vedic period
of 4500±1500 BC. In the Ayurvedic literature of Charaka
Samhita (which dates to 400 BCÐthe oldest existing
description of the complete Ayurvedic medical system),
epilepsy is described as `apasmara' which means `loss of
consciousness'. The Charaka Samhita contains abundant
references to all aspects of epilepsy including symptomatology, aetiology, diagnosis and treatment.
Another ancient and detailed account of epilepsy is on a
Babylonian tablet in the British Museum in London. This is a
chapter from a Babylonian textbook of medicine comprising
40 tablets dating as far back as 1067 BC. The tablet accurately
records many of the different seizure types we recognize
today. In contrast to the Ayurvedic medicine of Charaka
Samhita, however, it emphasizes the supernatural nature of
epilepsy, with each seizure type associated with the name of a
spirit or godÐusually evil.
Diagnosis posed problems for the ancients just as it does
today. The Greek physician Alexandros of Tralleis (525±605
BC) suggested: `wash the head of the patient and burn a ram's
horn under his nose and he will fall down'. (In ancient times,
the goat was considered the mammal that was most prone to
epileptic seizures.) In Roman times, people suspected of
epilepsy were given a piece of jet to smell. If the person did
442
Book reviews
not fall to the ground on smelling the stone, he was
considered `free of the falling sickness'. (This was a common
procedure when buying slaves.)
Those who have interested themselves in epilepsy, and
those who have dabbled in medical history will be familiar
with the many scholarly writings of Eadie on pharmacology,
and Bladin, founder of the epilepsy programme at Austin
Hospital in Australia.
This book, they say, is not intended to provide a general
history of epilepsyÐalready provided admirably by
Temkin's celebrated work The Falling Sickness (Temkin,
1971). But Eadie and Bladin are too modest, for in this
monograph they have produced a clearly written and well
constructed history. Temkin ended his account with the work
of Hughlings Jackson, whose insights constituted the beginnings of modern epileptology. The present authors extend this
to modern times, and clearly portray how technology has
changed our understanding of the protean clinical forms of
seizures, and to some extent shed light on the neuronal
mechanisms involved.
The organization of the text differs from the conventional,
combining many aspects of epilepsy and dealing with each
consecutively through history. The arbitrary, but reasonable,
time periods in history are used in successive sections.
Individual aspects thus dealt with are the phenomena
included within the concept of epilepsy at different times;
the perceived mechanisms in the epileptic process over the
generations; and the attempts at its remedy.
The principal focus lies in the development of the medical
understanding of epilepsy. However, in discussing this matter
the authors also discuss many aspects of the supernaturally
based ideas of the disorder, both to achieve perspective and
because, across the centuries, scienti®c and non-scienti®c
thinking have overlapped.
The idea that epilepsy is a supernatural, demonic or
spiritual disorder persisted with widespread beliefs that it was
due to possession by the devil, a notion which obtained
support from the miracle story of the cure of the epileptic
child recorded in three Gospels. Epilepsy was also viewed as
a result of a person perpetrating evil doings, or as a
consequence of cycles of the moon or mystic magical
phenomenon. Although Hippocrates (c. 400 BC) and his
followers regarded it as a physical disorder due to natural
causes, only in the 19th and 20th centuries have rational and
scienti®c notions replaced primitive concepts of the medical
Dark Age. Galen of Pergamon (AD 130±200) performed no
autopsies but described three types of ®ts, and deduced that
epilepsy was a brain disorder related to an accumulation of
thick humours. Galen says the moon governs the periods of
epileptic cases; hence, Greeks and Romans often regarded
them as lunatics.
Although there are many papers and texts dealing with the
history of epilepsy with varying degrees of detail, speculation
and accuracy, no one should doubt the dif®culties involved.
The interpretation of old concepts is at times confusing when
seen from the very different cultural scenes of the 20th and
21st centuries. The term `sacred disease' is held by the
authors as having being `used ironically, since the disorder
was anything but sacred in its nature. It was simply a physical
illness and not the product of some supernatural intervention.'
But this is a minor example of contemporary speculation of
how our forefathers might have thought about illness. In times
when scienti®c ignorance commonly caused invocations of
the deity or the supernatural, the term sacred disease may at
times have been intended literally.
The detailed description of epileptic ®ts and their changing
classi®cation is thorough and informative. Much centres on
Jackson's comprehensive studies, his remarkable histories of
a variety of attacks and his attempt to explain them as
discharges at various hierarchical and functional levels in the
brain. Eadie and Bladin are critical of some of his explanations, particularly seizure activity at lower pontobulbar
levels. But they accept that his de®nitions, ideas of origin and
spread of the epileptogenic focus and its relation to brain
pathology, were all fundamental and, in large measure,
original foundations for Gowers, Wilks, Wilson and many
other later writers. Psychological interactions with organic
seizures are not overlooked, for the authors expand the once
popular ideas of hysteria, hysteroepilepsy and even bizarre
psychoanalytic notions of the post-Freudians.
This is a comprehensive and worthy text and succeeds in
giving a clear picture of the facts and the often muddled
concepts about epilepsy through the ages. Many quotations,
sometimes from sources dif®cult to access, are a valuable
addition that enliven this splendid book.
J. M. S. Pierce
Anlaby, Hull,
East Yorks, UK
References
Temkin O. The falling sickness; a history of epilepsy from the
Greeks to the beginnings of modern neurology. 2nd edn. Baltimore:
Johns Hopkins University Press; 1971. p. 60.